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A systematic review of
the effects of early
intervention on motor
development
Cornill H Blauw-Hospers MSc;
Mijna Hadders-Algra* MD PhD, Department of Neurology
Developmental Neurology, University of Groningen,
Groningen, the Netherlands.
We present a systematic review on the effect of early In the past few decades the importance of early intervention
intervention, starting between birth and a corrected age of 18 (EI) has become widely recognized. But what exactly is EI?
months, on motor development in infants at high risk for, or Typically, a single definition is used, which applies to EI for chil-
with, developmental motor disorders. Thirty-four studies dren at biological risk for developmental disorders and
fulfilled the selection criteria. Seventeen studies were performed children with developmental disabilities. Early Intervention
within the neonatal intensive care unit (NICU) environment. consists of multidisciplinary services provided to children from
Eight studies had a high methodological quality. They evaluated birth to 5 years of age to promote child health and well-being,
various forms of intervention. Results indicated that the enhance emerging competencies, minimize developmental
Newborn Individualized Developmental Care and Assessment delays, remediate existing or emerging disabilities, prevent
Program (NIDCAP) intervention might have a temporary functional deterioration, and promote adaptive parenting
positive effect on motor development. Twelve of the 17 post- and overall family functioning. These goals are accomplished
NICU studies had a high methodological quality. They addressed by individualized developmental, educational, and ther-
the effect of neurodevelopmental treatment (NDT) and specific apeutic services for children provided in conjunction with
or general developmental programmes. The results showed mutually planned support for their families. 1 In general, EI
that intervention in accordance with the principles of NDT does programmes use techniques derived from the domains of
not have a beneficial effect on motor development. They also physiotherapy, occupational therapy, developmental psychol-
indicated that specific or general developmental programmes ogy, and education. Little attention is paid to the effect of
can have a positive effect on motor outcome. We concluded that nutrition, even though it is well known that the cognitive
the type of intervention that might be beneficial for infants at outcome of breastfed children is significantly better than that
preterm age differs from the type that is effective in infants who of formula-fed children.2
have reached at least term age. Preterm infants seem to benefit The earliest studies on EI programmes primarily addressed
most from intervention that aims at mimicking the intrauterine improvement in motor skills. Later, the focus shifted towards
environment, such as NIDCAP intervention. After term age, family-focused and other functional outcomes.3 It seems,
intervention by means of specific or general developmental therefore, that EI serves as an umbrella term covering the
programmes has a positive effect on motor development. whole field of childhood intervention.
One of the problems associated with the use of the term EI
is the interpretation of early. Early can be understood in
two ways, namely as early in life and as early in the expres-
sion of the condition. Each of the two types of earliness is
associated with advantages and disadvantages for interven-
tion. The major advantage of intervening early in life is that the
brain is considered to be very plastic at this time. The brain is
especially plastic in the phase occurring after the completion
of neuronal migration during which the processes of dendritic
outgrowth and synapse formation are highly active.4 This
means that high plasticity can be expected between 2 to 3
months before, and about 6 to 8 months after term age.5
See end of paper for list of abbreviations. However, there are two potential disadvantages that might be
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about the intervention method was given; of these, 10 stud- that started after discharge from the NICU, neurodevelop-
ies gave a more detailed description. To obtain some insight mental treatment (NDT), which consists of a mix of general
into the intervention strategies and procedures applied, we sensory stimulation and passive and active motor interven-
assessed whether programmes contained the following ele- tion strategies, was the intervention most frequently used.
ments: procedures to reduce stress, sensory stimulation Other frequently applied forms of intervention were various
(specific unimodal, specific multimodal, general multimodal), developmental programmes, which always included general
motor intervention strategies (passive handling techniques, sensory stimulation and general stimulation of motor devel-
active training of specific motor abilities, general motor train- opment but could also imply passive handling techniques
ing), and parentinfant interaction strategies (Table V). Both and the enhancement of parentinfant interaction.
authors assessed the composition of the intervention pro- Information about the period of application of the interven-
grammes independently. Interrater agreement was high: tion was supplied in 30 studies. Most NICU interventions were
Cohens kappa for the various components varied from 0.79 applied during variable periods, because most interventions
to 1.00. NICU intervention programmes consisted mainly of took place between the age of some postnatal days until dis-
combinations of procedures aimed at reducing stress, the charge. The application period in the post-NICU studies varied
provision of auditory, tactile, visual or vestibular stimuli, and between 2 months and more than 4 years. In addition, the
passive motor handling procedures. Among the programmes intensity of intervention showed considerable heterogeneity.
NICU
Als et al.13 38 20 18 0 HR I ++ ++
Resnick et al.8,9 255 107 114 13 HR I + +
Darrah et al.14 107 53 54 51 HR I + +
Ariagno et al.15 35 14 14 20 HR I + +
Charpak et al.17 746 382 364 16 HR I + +
Nelson et al.16 37 21 16 30 HR or CNS injury I + +
Kleberg et al.18 25 11 9 20 HR I + +
Tessier et al.19 431 183 153 22 HR I + +
Westrup et al.28 41 21 20 37 HR I +
Korner et al.21 56 12 8 64 HR I
Feldman et al. 24 146 73 73 9 HR II
Helders et al.25 149 67 82 34 HR II
Als et al.22 16 8 8 0 HR III +
Leib et al.20 28 14 14 0 HR III
Mouradian and Als 23 40 20 20 0 HR III
Becker et al.26 38 ? ? 61 HR III
Kleberg et al.27 33 15 18 ? HR III
After NICU to 9mo
Goodman et al.29 80 40 40 01 HR I ++ ++
Piper et al.30 134 66 68 14 HR I ++ ++
Leksculchai and Cole 34 84 43 41 14 HR I ++ +
Barrera et al.33 80 32 48 26 HR I ++ +
Weindling et al.32 105 51 54 21 HR of CP I ++ +
Rothberg et al.31 49 28 21 39a HR I + +
dAvignon et al.35 32 12/10b 8 6 HR I +
Kanda et al.36 10 5 5 0 CP III
918mo
Ulrich et al.37 30 15 15 0 DS I ++ ++
Palmer et al.10,11 48 25 23 2 CP I ++ ++
Reddihough et al.38 66 32 34 9 CP I + +
Mahoney39 50 28 22 0 CP/ DS II ++ +
Eickmann et al.40 156 78 78 13 Delayed cogn/mot dev II + +
Piper and Pless58 37 21 16 0 DS III +
After NICU to 18mo
Mayo42 29 17 12 0 Suspected CP I ++ +
Scherzer et al.43 24 14 8 8 CP I ++ +
Harris 41 20 10 10 0 DS I +
aIn time between two studies, 31 children were lost to follow-up. bTen infants received a different kind of intervention. C, control/contrast
group; CNS, central nervous system; CP, cerebral palsy; Delayed cogn/mot dev, delayed cognitive/motor development; DS, Down syndrome;
E, experimental group; HR, high risk; ?, no information available; +, high; ++, fair; , low.
NICU
Als et al.13 NIDCAP ++ 3d after birth ? Continuously Hp P
Resnick et al.8,9 Dev int ++ Birth 24mo Hp: daily Hp/Hm P
Hm: 2/mo
Darrah et al.14 Wb + 27d after birth Placement in Continuously Hp ?
open cots
Ariagno et al.15 NIDCAP + ? ? Continuously Hp P
Charpak et al.17 KC + 35d after birth Position no Continuously Hp P
longer accepted
Nelson et al.16 ATVV ++ 33wk PMA 2mo Hp: 15min, 2/d 5/wk Hp/Hm T
Hm: 2/d
Kleberg et al.18 NIDCAP + 1d after birth ? Continuously Hp P
Tessier et al.19 KC ++ Condition stable Discharge Continuously Hp P
Westrup et al.28 NIDCAP + 1d after birth 36wk PMA Continuously Hp P
Korner et al.21 Wb + <4d after birth Until evaluation Continuously Hp ?
Feldman et al. 24 KC ++ 3134wk PMA Discharge, >1h/d Hp P
duration 14d
Helders et al.25 T stim/RF Birth Discharge ? Hp ?
Als et al.22 NIDCAP ++ 9d after birth Discharge Continuously Hp P
Leib et al.20 Sens enr + Birth Discharge ? Hp ?
Mouradian and Als23 NIDCAP + ? <40wk PMA Continuously Hp P
Becker et al.26 Dev hand + Birth 36wk PMA ? Hp ?
Kleberg et al.27 NIDCAP + 3d after birth 36wk PMA ? Hp P
After NICU to 9mo
Goodman et al.29 NDT 3mo 12mo I: 1/mo >45min Hp/Hm P
P: daily (home
programme)
Piper et al.30 NDT + Term age 12mo I: 03mo: 1/wk Hm P
312mo: 1/2wk
P: daily
Leksculchai and Cole34 Dev pgm ++ Term age 4mo I: 1/mo Hm T
P: daily
Barrera et al.33 DPI/PIT + 4mo 16mo I: 47 mo: 12 h/wk Hm P
713 mo: 1/2wk
1316mo: 1/mo
Weindling et al.32 NDT Term age 12mo I: 06mo: 1/wk Hm ?
(CPcontinue) 69mo: 1/2wk
912mo: 1/mo
Rothberg et al.31 NDT + 3mo 12mo I: 1/mo >45min Hp/Hm P
P: daily (home
programme)
dAvignon et al.35 Vojta/NDT 47mo NDT: >3mo ? ? ?
Vojta: >6mo
Kanda et al.36 Vojta 1mo E: Mean duration E: 30min, 34/day Hm T
52mo
C: Mean duration
25mo
ATVV, auditorytactilevisualvestibular stimulation; C, control group; Ce, centre; CE, conductive education; Dev hand, developmental
handling; Dev int, developmental intervention; Dev mile, developmental milestones; Dev pgm, developmental programme; Dev S,
developmental skills; Dev stim, developmental stimulation; DPI, developmental programme intervention; E, experimental group;
Hm, home, Hp, hospital; I, instruction; IS, infant stimulation; KC, Kangaroo Care; mo, months (corrected age); NDT, neurodevelopmental
treatment; NIDCAP, Newborn Individualized Developmental Care and Assessment Program; P, parents; P, enhance parental skills;
PIT, parentinfant treatment; PMA, postmenstrual age; Phys T, physical therapy; Sens enr, sensory enrichment; T, parents are therapist;
T stim/RF tactile stimulation/range finding; TT, treadmill training; Wb, waterbed; ?, no information available. continued
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GENERAL EVALUATION OF EFFECTS (TABLES III TO VI ) the methodological strength of the studies.
Most studies evaluated the effect of intervention on motor
performance (1) during the intervention, (2) immediately EFFECT OF INTERVENTION STARTING IN THE NICU
after the end of intervention, and/or (3) some months or 1 to From the 17 NICU studies, eight had a high methodological
2 years after intervention. Various outcome measures were quality. These studies had an evidence level of I, a fair to high
used for effect evaluation. We categorized the measures as internal validity, and provided at least some possibilities for
either neuromotor, or tests that provide a more general generalization. In two of these eight studies a significantly
description of the childs developmental level (Table VII). positive effect of intervention on motor outcome could be
The Bayley Scales of Infant Development were most fre- demonstrated. One of the positive studies dealt with the effect
quently used as outcome measure for both neuromotor (Phys- of NIDCAP.13 The focus of intervention in this study was stress
ical Development Index; PDI) and developmental (Mental reduction in combination with general sensory stimulation.
Development Index; MDI) outcome. In 26 studies develop- The other intervention was aimed at improving the infants
mental tests were used to evaluate the effect of intervention. In general developmental level by means of a developmental pro-
nine of these, a beneficial effect of intervention on the develop- gramme including general sensory stimulation, general stimu-
mental parameters was reported. In 26 studies neuromotor lation of motor development, passive handling techniques,
tests were used. In 13 of these, study infants had a better neuro- and the enhancement of parentinfant interaction.8,9 In the
motor outcome than control infants. other six NICU studies of high methodological quality, inter-
Most studies were designed as randomized controlled vention had no statistically significant effect on motor develop-
trials. Twenty-three of the 34 studies had the highest level of ment.1419 The interventions used in these studies all included
evidence, namely level I, according to Sackett12 (see Table procedures to reduce the infants level of stress and multi-
I), four studies had a grade II level of evidence, and seven modal sensory stimulation (either specific or general), which
studies were classified as level III. Internal validity was high was or was not combined with passive motor intervention
in 11 studies, fair in 15, and low in eight. External validity techniques or the facilitation of parentinfant interaction.
was in general moderate only: in five studies generalization Five of the nine NICU studies with a lower methodological
was plausible, 17 studies offered some possibilities for gen- quality pointed to a positive effect of intervention.2024 Inter-
eralization, and 12 studies had low external validity. The vention used in these studies consisted of various combina-
validity of post-NICU studies was usually better than that of tions of procedures to reduce stress, multimodal sensory
NICU studies. stimulation, passive motor intervention strategies, or the
In the next sections we report the effects of intervention facilitation of parentinfant interaction. The remaining four
on motor development for the different age periods during studies were unable to demonstrate a beneficial effect of
which intervention had started, while taking into account intervention.2528
918mo
Ulrich et al.37 TT + 912mo Independent 8min/d, 5d/wk Hm T
walking
Palmer et al.10,11 NDT/IS ++ 1219mo Duration 12mo I: 1h 1/2wk Ce/Hm P
P: daily (home
programme)
Reddihough et al.38 CE ++ 1236mo Duration 6mo E: 2.8h/wk Ce ?
C: 2.9h/wk
Mahoney39 NDT/Dev S + Mean age 14mo Duration 12mo 3/mo, 45min Ce/Hm ?
Eickmann et al.40 Dev stim + 13mo 18mo I: 11 home visits Hm P
3045min,
3 workshops
Piper and Pless58 Dev mile + Mean age 9mo Duration 6mo I: 1h 1/2wk Ce/Hm P
P: home programme
After NICU to 18mo
Mayo42 NDT + 418mo Duration 6mo E: 1h/wk Hp/Hm P
C: 1h/mo
Scherzer et al.43 Phys T + 517mo 24mo 1h 1/2wk Hm T
Harris41 NDT ++ 221mo Duration 9wk E: 3/wk >40min Hm ?
ATVV, auditorytactilevisualvestibular stimulation; C, control group; Ce, centre; CE, conductive education; Dev hand, developmental
handling; Dev int, developmental intervention; Dev mile, developmental milestones; Dev pgm, developmental programme; Dev S,
developmental skills; Dev stim, developmental stimulation; DPI, developmental programme intervention; E, experimental group;
Hm, home, Hp, hospital; I, instruction; IS, infant stimulation; KC, Kangaroo Care; mo, months (corrected age); NDT, neurodevelopmental
treatment; NIDCAP, Newborn Individualized Developmental Care and Assessment Program; P, parents; P, enhance parental skills;
PIT, parentinfant treatment; PMA, postmenstrual age; Phys T, physical therapy; Sens enr, sensory enrichment; T, parents are therapist; T
stim/RF tactile stimulation/range finding; TT, treadmill training; Wb, waterbed; ?, no information available.
Waterbed14,21 + + +
ATVV intervention16 + +
NIDCAP13,15,18,22,23,27,28 + + + +
KC17,19,24 + + + +
Developmental handling26 + + + ?
Treadmill training37 + +
Tactile stimulation/range finding25 + +
Vojta35,36 + +
Sensory enrichment20 +
Developmental intervention8,9 + + + +
NDT10,11,29-31,35,39,4143 + + +
Developmental programme34 + + +
Developmental milestones58 + + +
Developmental stimulation40 + + +
Developmental parent intervention33 + + +
Infant stimulation10,11 + + +
Conductive education38 + +
Developmental skills39 + + ?
Parentinfant treatment33 +
Notes
Stress reduction: decreasing stressful events to body by restricting input from environment until infant is capable of maintaining an adequate
organization of its behavioural state; placing infant in such a way as to provide a sense of containment similar to intrauterine environment.
Sensory stimulation: (a) specific unimodal: procedures during which a single sensory modality is stimulated (e.g. specific tactile
stimulation); (b) specific multimodal: procedures during which multiple specific sensory modalities are stimulated (e.g. ATVV, which consists
of application of auditory, tactile, visual, and vestibular stimuli); (c) general multimodal: procedures during which multiple forms of not
explicitly described sensory stimuli are applied (e.g. verbal and tactile encouragement as part of general developmental programmes).
Motor intervention strategies: (a) passive procedures: therapist or parent performs specific techniques, which do not require active motor
behaviour of child, i.e. child has a passive role (e.g. handling, positioning, and facilitation procedures); (b) active specific: child is encouraged
to actively train a specific motor ability (e.g. walking by means of treadmill training); (c) active general: child is encouraged to train a variety of
motor abilities; stimulation of activities occurs in general by means of structured activities, which are designed to meet childs developmental
level. Practice and play are important elements in this last type of intervention.
Enhancing parentinfant interaction: parents receive information on infant behaviour. Increased knowledge on infantile behaviour facilitates
parents sensitivity to childs needs and promotes developmentally supportive behaviour. +, procedure used; , procedure not used; ?, no
information available; PII, parentinfant interaction. For other abbreviations see legends to Table IV.
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EFFECT OF INTERVENTION STARTING BETWEEN NICU DISCHARGE Discussion
AND 18 MONTHS CORRECTED AGE We are not the first to write a review on the effects of EI for
The three studies in which intervention started between children at high risk for developmental disabilities; others
discharge from the NICU and a corrected age of 18 months have preceded us.6,4450 The major conclusion from these
were all level I studies (see Table I) with a moderate to high reviews is that the evidence favouring EI is inconclusive.
internal validity and a moderate external validity. Two studies Results from this present review indicate that we have moved
evaluated the effect of NDT. The study that assessed the effect a little way forwards. In the following sections we shall point
of a short period of intensive NDT was unable to demonstrate out the direction of progress. However, before we address the
a significant effect of intervention on motor development;41 issues of which programme is best applied and at what age,
the other, which applied less intensive NDT for half a year, we first discuss some methodological issues.
reported a positive effect of intervention on motor develop-
ment.42 The third study evaluated the effect of a general physi- METHODOLOGICAL CONSIDERATIONS
cal therapy programme and did not find a significant beneficial The studies included in this review were very heterogeneous
effect of the intervention on motor development.43 in nature. A large variation existed not only in the number of
NICU
Als et al.13 1 9 APIB, Bayley PDI Bayley MDI E>C
Resnick et al.8,9 12 24 Bayley PDI Bayley MDI E>C
Darrah et al.14 1 + 4,8 12 18 MAI Peabody E=C
Ariagno et al.15 1 1,4 12 24 Bayley PDI, NAPI, APIB Bayley MDI E=C
Charpak et al.17 + 3,6 9, 12 Griffiths E=C
Nelson et al.16 2,4 12 Bayley PDI Bayley MDI E=C
Kleberg et al.18 12 Bayley PDI Bayley MDI E=C
Tessier et al.19 12 Griffiths E=C
Westrup et al.28 66 Movement ABC E=C
Korner et al.21 1 LAPPI E>C
Feldman et al. 24 1 3,6 Bayley PDI Bayley MDI E>C
Helders et al.25 Pre, after PM Dev E=C
2wk, weekly
till discharge
Als et al.22 4 + 1,3,6 9 APIB, Bayley PDI Bayley MDI E>C
Leib et al.20 2 6 Bayley PDI, NBAS Bayley MDI E>C
Mouradian and Als23 1 APIB E>C
Becker et al.26 3 VA E=C
Kleberg et al.27 36 Griffiths E=C
After NICU to 9mo
Goodman et al.29 6 9, 12 Griffiths E=C
Piper et al.30 6 12 Wolanski Milani, Griffiths E=C
Leksculchai and Cole34 + 1,2,3,4 TIMP E>C
Barrera et al.33 4 16 Bayley PDI Bayley MDI E>C
Weindling et al.32 12 30 MAI Griffiths E=C
Rothberg et al.31 72 GriffithsII E=C
dAvignon et al.35 3672 CP class E=C
Kanda et al.36 1,2,3,5 Every 3 mo 59 Clin Neur Ex E>C
918mo
Ulrich et al.37 Every 2 wk Bayley PDI Bayley MDI E>C
Palmer et al.10,11 18,24 Bayley PDI Bayley MDI E<C
Reddihough et al.38 Prepost GMFM E=C
Mahoney39 14, 26 Bayley MDI, Peabody E=C
Eickmann et al.40 12 18 Bayley PDI Bayley MDI E>C
Piper and Pless58 Prepost Griffith E=C
After NICU to 18mo
Mayo42 Pre Post Wolanski Bayley MDI, Gesell E>C
Scherzer et al.43 Pre 24 MDC Gesell E=C
Harris41 Pre Post Bayley PDI Bayley MDI, Peabody E=C
aFor explanation of abbreviations see Table VII. bStatistically significant differences found in motor outcome at oldest age of evaluation:
E>C, experimental group significantly better outcome than control group; E=C, no difference between groups; E<C, control group better
outcome than experimental group.E, experimental group; C, control group; Pre, before intervention; Post, after intervention; +, present;
, absent.
Table VII: Classification of outcome measures into neuromotor tests and developmental tests
Bayley Scales of Infant Development BayleyPDI 1969, 1993 Griffiths Developmental Scales Griffiths 1954, 1970
Psychomotor Development Index MilaniComparetti Motor Milani 1967
Development Screening test
Wolanski Gross Motor Evaluation Wolanski 1973 Bayley Scales of Infant Development Bayley MDI 1969, 1993
Neonatal Behavioral Assessment Score NBAS 1973, 1984 Mental Development Index
Motor Development Checklist MDC 1976 Gesell Developmental Schedules Gesell 1974
Movement Assessment of Infants MAI 1980 Peabody Developmental Motor Scales Peabody 1974
Assessment of Preterm Infants Behavior APIB 1982 Muenchener Funktionelle MFED 1978
Longitudinal Neurobehavioral LAPPI 1983 Entwicklungs Diagnostik
Assessment Procedure for Preterm Infants Psychomotor Development profile PM Dev 1981
Supplemental Motor Test for Postural PoCo 1987 (based on Gesell)
Control
Neurobehavioral Assessment of the NAPI 1990
Preterm Infant
Movement Assessment Battery for Movement ABC 1992
Children
Gross Motor Function Measure GMFM 1993
Test of Infant Motor Performance TIMP 1995
Video-analysis (amount and variation VA 1999
in movements)
Clinical neurological examination Clin Neur Ex nfs
CP classification CP class 1981
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One demonstrated a significant positive effect on motor devel- POST- NICU STUDIES
opment, as measured by the Psychomotor Index of the Bayley Of the 17 studies that started after the NICU period, 12 had a
Scales of Infant Development (BayleyPDI13), but the other high methodological quality. Only four of these were able to
two did not reveal such an effect on BayleyPDI.15,18 The differ- show a beneficial effect of intervention on motor develop-
ence in outcome between the three studies might be attributed ment. Eight of the 12 studies evaluated the effects of NDT or
to the age at which outcome was assessed. Outcome in the physiotherapy, mainly on the basis of the principles of NDT.
positive effect study of Als et al.13 was evaluated at 9 months It is striking that only one of these studies reported a better
corrected age, and in the two no effect studies at 12 and 24 motor outcome in the experimental group than in the con-
months. It could be, therefore, that NIDCAP has a temporary trol group.42 The positive effect study of Mayo42 differed
beneficial effect on motor development of infants at high risk from the other studies in being the only one that compared
for developmental disorders. This notion is in line with results intensive NDT treatment (once a week) with less intensive
of two recent meta-analyses which concluded that NIDCAP has NDT (once a month). The other eight studies compared
a temporary beneficial effect on cognitive and motor develop- NDT with infant stimulation10,11 or with a form of standard
ment.53,54 However, it should be kept in mind that only the care that was not defined further. In six of the seven studies,
study by Westrup et al.28 assessed the effect of NIDCAP beyond motor outcome in the NDT group was similar to that of the
the age of 2 years but was unable to demonstrate a significant contrast group. In the seventh study, motor development
positive effect of NIDCAP on developmental outcome at the was worse in children treated in accordance with the princi-
age of 512 years. Nevertheless, considering reports that NIDCAP ples of NDT than in children who received an infant stimula-
intervention in low-risk preterm infants has a significant posi- tion programme.10,11 The above studies indicate that NDT
tive effect on electrophysiological and magnetic resonance during the first years of life does not have a measurable posi-
imaging correlates of brain development at 42 weeks postmen- tive effect on motor development. This is in line with the
strual age,55,56 it is conceivable that NIDCAP might affect com- conclusion of a recent review on the effects of NDT for peo-
plex motor behaviour and cognitive abilities at school age. It ple with CP, aged 5 months to 22 years, which stated that
might be that this putatively positive effect will be found in par- NDT did not have a clear beneficial effect on developmental
ticular in low-risk and not high risk preterm infants. outcome.57
Two other high-quality studies used Kangaroo Care to The other four high-quality studies evaluated the effects of
improve motor outcome.17,19 The application of Kangaroo a developmental programme, treadmill training, or conduc-
Care had no effect on developmental outcome as measured tive education. The two developmental programme stud-
by the Griffiths Developmental Scales at 6 and 12 months ies33,34 and the treadmill training study37 reported a positive
corrected age. Two explanations for this result can be effect of intervention on motor development. The fourth
offered. First, it could be that Kangaroo Care does not affect study compared the effect of conductive education with that
motor development. It is likely that the effect of the relatively of traditional neurodevelopmental programmes. Both types
simple Kangaroo Care is weaker than that of the rather com- of intervention were associated with similar degrees of devel-
plex NIDCAP programme. Second, it is possible that the opmental progress.38
effects are too subtle to be detected by the Griffiths scales. Treatment according to Vojta was evaluated in only two
Two high-quality studies applied intervention strategies studies: dAvignon et al.35 compared, in a small randomized
consisting of procedures to reduce stress in combination with trial with a limited methodological quality, the effect of treat-
specific multimodal sensory stimulation, with or without pas- ment according to Vojta with NDT. They reported that the
sive motor intervention procedures.14,16 Neither study was groups did not differ significantly in developmental outcome.
able to find a positive effect of intervention on motor develop- Kanda et al.,36 who studied the effect of the amount of Vojta
ment at 12 and 18 months corrected age. treatment on developmental outcome, reported a better out-
The last high-quality NICU study showed that developmen- come for the group that received sufficient Vojta training than
tal intervention had a significant positive effect on motor devel- for the group that had received insufficient Vojta therapy.
opment.8,9 In this programme, intervention started in the However, a major drawback of the study is that the design suf-
hospital with vestibular and visual stimulation to promote fered from self-selection of the groups.
development. After discharge, intervention was continued for 2 Thus, the current review indicates that intervention pro-
years by means of a developmental programme in the home sit- grammes in the first postnatal years, according to the prin-
uation. Parents had an important role in performing the inter- ciples of NDT or Vojta, do not have a beneficial effect on
vention programme, which consisted of 400 different motor, motor development in children at high risk for develop-
social and cognitive activities complemented by several parent- mental disorders or in children with CP or Down syn-
ing activities. The positive outcome of the intervention can drome. However, substantial evidence has been provided
probably be attributed more to the duration of the programme which suggests that specific developmental training and
and the continuous involvement of the parents in the develop- general developmental programmes in which parents learn
ment of their children than to the NICU part of the intervention. how to promote infant development can produce a positive
In conclusion, the present review provides little evidence effect on motor development.
that intervention during the NICU period in infants at high
risk for developmental disorders has a beneficial effect on Conclusion
motor development. However, a potential advantageous The present review indicates that intervention in children
effect of NIDCAP on motor development cannot be exclud- at risk of developmental disabilities should be adapted to
ed. We recommend that further studies address the effect of the infants age, i.e. the type of intervention that might be
NIDCAP on developmental outcome at school age in low-risk beneficial for infants at preterm age differs from the type that
and high-risk preterm infants. is effective in infants who have reached at least term age.
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